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Breaking the silence: Should health workers ask about domestic violence?

In an emergency department in Calgary, a woman says she slipped on the ice, but her injuries don’t match a fall. In a private setting, the nurse begins to talk to her about domestic violence. Initially, the patient insists that she slipped, but after a long conversation, the nurse and the patient call the police together. Her partner is arrested in the waiting room.

As the domestic violence program coordinator for Calgary, Linda McCracken trains emergency department and urgent care centre nurses to initiate these discussions with every patient over 14 years old. All Calgary Zone EDs have a universal screening program in place – meaning everyone who comes through the ED is asked about intimate partner violence, and whether they feel safe in their homes.

Both routine and emergency visits give health care providers the opportunity to screen for IPV. Research says universal screening significantly increases the number of women identified as victims of domestic violence, compared to only asking women when it’s suspected. Screening has not been shown to cause adverse effects.

Typically, universal screening means asking women, but some hospitals – including those in the Calgary zone – screen both men and women. Though nearly 80% of domestic violence victims are women, some argue that men should be screened in health care settings because IPV against men, in both same-sex and heterosexual relationships, goes underreported. Usually, the question is asked privately in the assessment stage, or later if emergency care needs to be prioritized.

While screening can be done at all levels of health care, from family practices to EDs, this article focuses on hospital-level screening, as the available research tends to have been conducted in hospital programs.

Currently, many hospitals across Canada do not have programs that mandate screening. Out of 12 departments across eight hospitals, researchers at the Centre for Research on Inner City Health (CRICH), could find only two EDs and one antenatal department with routine, universal screening.

These programs are becoming more common, however. St. Michael’s Hospital, Toronto initiated a universal screening program for IPV in 2010, the Ottawa Hospital three years ago, and in 2014, provincial guidelines on screening for domestic violence were created for all urgent care centres in Alberta.

Part of the reason that hospitals are only beginning to screen may relate to a lack of evidence that patients who disclose end up better off for it — though advocates of screening say that’s simply because the comprehensive long-term trials haven’t been done.

The challenges of screening

Kari Sampsel runs the Sexual Assault and Partner Abuse Care Program in The Ottawa Hospital. Three years ago, she convinced the hospital ED to add a question about domestic violence to the patient’s triage form. “How often they get asked is another matter,” she says. Indeed, even when universal screening protocols are in place, they’re not always followed due to challenges from privacy issues, and lack of time and confidence on the part of providers.

Like all emergency departments, The Ottawa Hospital’s ED is far from private. Patients’ partners often accompany them, especially if they are victims of domestic abuse. Even if the partner is absent, there is only a thin curtain separating a potential victim from other patients. Nurses, who are usually tasked with asking these questions, may be uncomfortable, or just too busy, which also leaves many women unscreened.

According to Katherine Wallace, a registered nurse and lead program manager for the Registered Nurses’ Association of Ontario’s work on domestic violence, a patient disclosing can be likened to “opening Pandora’s box.” The counselling expertise and time it can take to help a victim of domestic violence is intimidating. Sometimes, hospitals implement screening, but don’t provide adequate training or guidelines to staff on how to intervene properly or how to refer patient to shelters, counselling or social workers. Without adequate training, even experienced nurses might be afraid they won’t know how to help.

The stigma surrounding domestic violence is another factor, says Christine Bradshaw, chair of the Violence Against Women Awareness Committee at Mt. Sinai Hospital. Bradshaw, who has been educating all staff in her hospital on domestic violence for years, says simply discussing domestic violence openly is the best way to counter stigma. One common stigma-related stereotype is that it is possible to tell if someone is at risk of experiencing domestic violence just from their appearance. But, as Sampsel adds, “It can happen to anyone, not just low income families.”

Innovative solutions for domestic violence screening

Patricia O’Campo and her team of researchers at CRICH in Toronto are working on the development of an IPV screening app to address the challenges of health worker time constraints and their discomfort in asking the question. Though it’s still in the early stages, the app would allow patients to either respond to the question on an iPad in the waiting room or download the app to their phone so that they could read information and respond to questions wherever they feel most safe, explains Rachel Yantzi, one of the researchers. The app could also be accessed on a website from a secure computer at a library or school. For patients who identify abuse, a list of resources may be provided, or a social worker would be contacted with the patient’s permission. This could circumvent health worker’s fear of opening Pandora’s box.

Four clinics across Toronto are interested in hosting trials for the app, including St. Michael’s Hospital Fracture Clinic, which has been universally screening women over 16 years old since 2013 — thanks to their past head of orthopaedic surgery Emil Schemitsch’s study PRAISE. They discovered that one in six women visiting orthopaedic fracture clinics had experienced IPV in the past year, and only 6% of women had ever been asked about IPV by a health care provider.

Another way to advance screening efforts is to implement them at numerous different levels of care so that even if a patient is missed at one site, the opportunity will be there at the next. “I don’t think there’s any place you can’t ask,” says McCracken. She adds that if patients are asked every visit, in every health care setting, and see posters about domestic violence, that will send the message that the problem is taken seriously by health care providers.

Managerial and administrative support play an integral role in assuring success of these programs, says McCracken. Some of Calgary’s urgent care centres’ screening rates have doubled thanks to managerial support. One manager sends out reminders to screen in memos, and includes it in her yearly review of staff, according to McCracken. As part of a Calgary wide push for compliance, McCracken sends out reports on screening rates at each centre: “If you put it in graph form it gets to be sort of a competition, though of course competition shouldn’t be the reason providers screen.”

The evidence on screening for domestic violence

According to a Cochrane meta-analysis of six trials in diverse health care settings, screening doubles the identification of women who experience IPV. Out of 1,885 women who were only asked if health-care workers suspected domestic violence, 60 disclosed abuse, and out of 1,679 women who were universally screened, 120 disclosed. The question is whether those women who are identified are helped afterward. Unfortunately, the evidence so far isn’t clear. Another Cochrane meta-analysis of three studies did not find that screening statistically increased referrals to support services. A separate review found examples where screening did result in a reduction of IPV, but the studies weren’t high-quality.

The conflicting evidence might be due to the newness of IPV screening programs. Many have yet to be evaluated, and might not yet have good linkages with support services. Advocates argue that in theory, screening would work if health care providers are comfortable with the responsibility of intervening and had the resources and time to assess and assist the victim. In the team’s future studies, Yantzi says it will be important to closely monitor whether screening is handled properly, and whether patients are getting the referrals they need. “The goal is to spend a lot of time coaching the staff through the process,” she says.

Domestic violence is carried out and remedied over many years, making it difficult to get quick results from studies. Long-term evaluation – necessary to show that women are not only identified but helped – would likely have to span many years to show benefits. Women might need to be asked multiple times before they feel ready to disclose, and studies show that it can take many efforts for a woman to leave an abusive partner. But long-term studies require money and considerable effort. Sampsel reflects the challenges of evaluation when she explains her ED hasn’t done a study on the effects of their screening program due to “a lack of time and resources.”

Another potential barrier to showing that screening leads to an increase in referrals to services could be because community supports and resources are either scarce or nonexistent. The magnitude of the battle against IPV is not a reason to drop funding, says Yantzi — it should mean the opposite, along with funding for more social infrastructure: “Counselling, housing services… strengthen all of these things and identification will have a bigger impact.”

Until further evidence is established, the success of screening programs can still be judged according to how consistently nurses screen, and Yantzi says there is minimal to no risk in asking the question, so why not try? Screening may not fix the problem, but “it is sort of an intervention in itself,” she says. “It helps reframe what a normal relationship is.”

Yes, absolutely – health-care professionals should integrate assessment of domestic violence into their practice. Moreover, it is imperative that violence be addressed at the societal, organizational, and individual levels.

The Registered Nurses’ Association of Ontario (RNAO) first spoke on this issue in 2008 when it released the “Zero Tolerance of Violence Against Nurses” policy statement aiming to ensure safe practice settings for all health-care providers (link: http://rnao.ca/policy/position-statements/violence-against-nurses). Then in 2012 RNAO recommended this be a universal practice for nurses and other health professionals with the release of its Best Practice Guideline on Woman Abuse: Screening, Identification and Initial Response (link: http://rnao.ca/bpg/guidelines/woman-abuse-screening-identification-and-initial-response). This guideline recommends that all nurses implement routine universal screening for women in all health-care and community settings as highlighted in the Breaking the Silence article.

Nurses witness in their professional and private lives the devastating outcomes of abuse. And, it was the tragic loss of nurses’ lives that triggered the association to first release a policy statement in 2008 and later on an evidence-based practice guideline.

Remember Lori Dupont of Windsor, Zahra Abdille of Toronto, Sonia Varaschin of Orangeville. These three nurses were brutally killed. And, so was RN Nathalie Warmerdam, a 48-year old mother of two who lived in Eganville, just outside Ottawa – shot in a horrific and calculated killing by her ex partner. Nathalie wasn’t the only woman killed that day. The man who killed her also killed two other women, who were ex partners of the accused.

Intimate partner violence (IPV) continues to be a leading public health problem with serious health consequences and one of the most common forms of violence against women. Routine universal screening increases opportunities for early identification and effective interventions provided through health-care organizations working together with the community to integrate services between sectors.

Nurses are best positioned to screen for IPV as they are accessible, are trusted by the public, and work across all health sectors. Nurses also provide care to women during times of transition such as pregnancy and parenthood, illness and stress, and frequently are the first member of the interprofessional team to interact with women who may be experiencing abuse. However, screening is not enough and as RNAO’s evidence-based guideline on this topic reinforces, nurses and all health professionals must be equipped with the necessary knowledge and skills to also respond appropriately to incidents of woman abuse. They also must be encouraged to use reflective practice to examine how their own beliefs, values, and experiences influence the practice of screening. This requires comprehensive education, ongoing organization policy, and managerial support, so that nurses and others can foster awareness and sensitivity about woman abuse. In addition, education needs to focus on assisting nurses to carry out appropriate follow up and referral as necessary, know what to document when screening for and responding to abuse, and understand their legal obligations when a disclosure of abuse is made.

The health-care provider’s initial response to a woman experiencing abuse is of great importance, as women may not disclose their experiences due to fear, shame or guilt. Thus, it is essential that RNs create an environment of openness, safety, and trust to facilitate disclosure. Screening protocols for IPV must be formally adopted by an organization and need to be flexible to fit the context of an individual situation. Organizational protocols may vary depending on factors such as the health-care setting, the presenting problem and the person’s history. Furthermore, screening strategies and initial responses that reflect the needs of all women taking into account differences based on race, ethnicity, age, ability, sexual orientation religious / spiritual beliefs and culture, must be developed and put into practice.

As documented in another of RNAO’s research based guidelines, Preventing and Managing Violence in the Workplace (2009), multiple studies have demonstrated that a significant proportion of IPV experienced by women is transferred into the workplace (link: http://rnao.ca/bpg/guidelines/preventing-and-managing-violence-workplace). Governments can promote a workplace free from violence, including IPV, by developing and monitoring organizational accountability including fair and consistent responses to the reporting of violence. Organizations should develop and implement a violence prevention policy that addresses all forms of violence or potential violence in the workplace. All employees, including health workers, should acquire the knowledge and competencies of, contribute to, and fully adhere to organizational policies that prevent, identify, and respond to violence.

The routine universal screening for IPV validates woman abuse as a central and legitimate health care issue is relevant to all sectors. It enables nurses and other members of the interprofessional team to assist both victims and their children and can be ultimately a life savings measure.

So how does one who promotes including universal screening for domestic violence as part of all health assessments counter the challenges (mainly from physicians) to this practice based on conclusions from the abridged Cochrane systematic review and meta-analysis?… “there is insufficient evidence to justify screening in healthcare settings”

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.